New alerting will spread safety risk warnings more quickly

A new alerting system launched today by NHS England will ensure warnings of potential risks to the safety of patients can be developed much more quickly and be rapidly disseminated right across the NHS.

The new National Patient Safety Alerting System (NPSAS) will ensure warnings of emerging risks can be rapidly issued following their identification by the NHS England Patient Safety Domain. As part of the new process, by April 2014 NHS England will also begin publishing monthly data on trusts who fail to confirm they have complied with the required actions of an alert within the set timeframe.

Until now, information about risks identified through the National Reporting and Learning System (NRLS) has been distributed through a range of different mechanisms including Patient Safety Alerts and Rapid Response Reports. This system was effective, but the development, consultation and agreement process was lengthy, meaning it was often difficult to issue timely alerts.

The new system has three stages and is based on those used in other high-risk industries like aviation. Now, when a potential risk to safety is identified:

  • A Stage One “warning” alert is issued to ensure healthcare staff are made aware of the potential issue at the earliest opportunity. This allows hospitals, clinics and other healthcare organisations to assess similar risks in their own organisations, and take immediate action.
  • If the Stage One alert requires further action, a Stage Two “resource” alert will follow, with more in-depth information and advice. Stage Two alerts will include examples of good practice to mitigate the risk that have been shared by providers following a Stage One alert; access to resources to help introduce new measures to reduce risks; and access to relevant training programmes.
  • If necessary, a Stage Three “directive” alert will be issued, requiring organisations to confirm that they have undertaken specific actions and introduced specific processes to mitigate the risk.  Providers will be issued with a checklist of required actions, tailored to the individual issue, and will need to confirm these actions have been taken within a set timeframe.

Alerts will be distributed through the Central Alerting System, which is already used to send out alerts from other bodies, such as Medicines and Healthcare Products Regulatory Agency (MHRA) and the Chief Medical Officer.

Trusts who fail to declare they have complied with any of the three stages of alert within the set timeframes will be named in monthly data, which will start to be published on the NHS England website by April 2014. This information will be publicly available and we expect it to be used by the CQC as part of their systems for identifying Trusts in need of inspection, and by other regulators and commissioners in holding their local services to account.

NHS England’s Director of Patient Safety, Dr Mike Durkin, said: “Almost all treatments and procedures carried out by the NHS carry some inherent risk – the science of patient safety is all about identifying and minimising those risks. The National Patient Safety Alerting System will ensure that no identified risk or potential risk to patient safety is held up in a long process of consultation and discussion before it is highlighted to every part of the NHS. It will also ensure that individual providers have very clear instructions on how to minimise risks, and that they clearly account for what they have done to fulfil them.

“Patient safety is now more than ever at the forefront of the minds of those providing NHS care, and thanks to the efforts of frontline staff we are continuing to take great strides in making healthcare settings safer and preventing harm to patients. We have come a long way in shifting the culture of the NHS since the establishment of the National Patient Safety Agency (NPSA) in 2001, when patient safety was a new discipline and seen as an add-on to the core business of treating patients.

“The NPSA built reporting and alerting systems from scratch, and made patient safety a central part of every discussion about patient care. Under the reforms of the health service, the NPSA’s functions were taken on by NHS England, firmly embedding patient safety where it should be, at the heart of our health service.

“Last year, in his landmark review into patient safety in England, Professor Don Berwick said that the NHS has the potential to become the safest healthcare system in the world. We are determined to make that a reality, and this new alerting system is an important step towards that.”

Further information about the National Patient Safety Alerting System is available on the NHS England website, including the An introduction to the NHS England Patient Safety Alerting System guide that has been produced to help healthcare providers be prepared for receiving the new alerts.

Elaine Inglesby-Burke, Executive Nursing Director at Salford Royal NHS Foundation Trust, was a member of the National Advisory Group on the Safety of Patients in England, which advised Prof Berwick in making recommendations for patient safety across the NHS.

She said: “I’m very happy to see that progress is already being made with the recommendations that we believe are key to making the NHS as safe as possible.

“Having a system for patient safety alerts which can notify the NHS about risks to safety more quickly, and which can monitor compliance more robustly, is an essential way to make sure the whole service learns when things have gone wrong and we know what needs to be done to prevent it from happening again.

“This recommendation was particularly important to the patient representatives on the group, and so it’s right that it was a high priority for NHS England.”